A nurse is preparing to transfer a client who is immobile and weighs 104.3 kg (230 lb) from the bed to a stretcher. Which of the following actions should the nurse plan to take?
Apply a transfer belt to the client prior to transferring to the stretcher.
Move the client onto the stretcher using a slide board with the assistance of two health care workers.
Have the client roll onto a transfer board and pull the board onto the stretcher.
Move the client's upper body onto the stretcher first.
The Correct Answer is B
Rationale
A. Apply a transfer belt to the client prior to transferring to the stretcher: Transfer belts are used for clients who can stand or provide some degree of weight-bearing support. An immobile 104.3-kg client cannot safely assist with the transfer, making the belt ineffective and unsafe. Using a transfer belt in this scenario increases the risk of falls and caregiver injury.
B. Move the client onto the stretcher using a slide board with the assistance of two health care workers: A slide board reduces friction and allows the client to be moved laterally as a single unit, which is the safest method for an immobile client of this weight. Using at least two trained staff members prevents strain and ensures coordinated movement.
C. Have the client roll onto a transfer board and pull the board onto the stretcher: This technique requires the client to participate by rolling, which is not feasible for someone who is immobile. Pulling a transfer board with the client on it creates unnecessary shear forces that increase the risk of skin breakdown. This approach is neither safe nor appropriate for a heavy, immobile patient.
D. Move the client's upper body onto the stretcher first: Moving the client unevenly in sections can cause spinal misalignment and increases the risk of caregiver injury due to poor body mechanics. This technique also creates friction on the client’s skin and may cause discomfort or tissue injury. A coordinated lateral transfer keeps the body aligned and is recommended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale
A. Ask the client to occlude one ear with a finger: Occluding one ear is part of the Rinne test, not the Weber test. The Weber test assesses lateralization of sound and does not require the client to block either ear initially.
B. Place a vibrating tuning fork against the midline vertex of the client's head: In the Weber test, the vibrating tuning fork is placed on the midline of the skull, usually the forehead or vertex. This allows the nurse to assess whether sound is heard equally in both ears or lateralizes to one, helping differentiate between conductive and sensorineural hearing loss.
C. Whisper words for the client to identify: Whispered voice testing evaluates the client’s ability to hear and repeat words, but it is a separate assessment from the Weber test and does not determine lateralization.
D. Have the client repeat a phrase spoken by the nurse while the nurse's mouth is hidden: This describes the whispered voice or speech discrimination test, not the Weber test. The Weber test focuses on bone conduction and sound lateralization rather than speech comprehension.
Correct Answer is A
Explanation
Rationale
A. Guided imagery: Guided imagery is a relaxation technique that uses mental visualization to reduce anxiety and promote calmness. It is safe, noninvasive, and can be implemented immediately before surgery to help the client manage preoperative stress.
B. Acupuncture: While acupuncture may help with pain or anxiety, it requires a trained practitioner and time to perform. It is not practical as a short-term intervention immediately prior to surgery.
C. Herbal medicine: Herbal remedies are not recommended immediately before surgery because they can interact with anesthesia and other medications, potentially increasing bleeding risk or affecting drug metabolism. Safety concerns limit their use in the preoperative period.
D. Magnet therapy: Magnet therapy lacks evidence for reducing anxiety and is not a standard complementary therapy for preoperative stress. Recommending it would not provide meaningful benefit for surgical preparation.
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